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This is a talk from IPOS 2010 on Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice: A Multicentre UK Study.
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Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
IPOS 2010
T125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice:A Multicentre UK Study
T125 - Identification of Patient Reported Distress by Clinical Nurse Specialists in Routine Oncology Practice:A Multicentre UK Study
1. Background
What are the issues in detection
How do PCPs compare?
What are the special issues in the older person
What are the issues in physical disease
% Receiving Any treatment for Depression
10.9 11.3
8.18.8
4.3
5.6
10.9
13.8
6.8
17.9
3.4
5.5
15.4
7.2
0
2
4
6
8
10
12
14
16
18
20
High Inc
omeBelg
ium
France
German
y
Israe
l
Italy
Japa
nNeth
erlan
dsNew
Zeala
nd
Spain USALow
Inco
me
ChinaColom
biaSouth
Afri
caUkra
ine
Wang P et al (2007) Lancet 2007; 370: 841–50
n=84,850 face-to-face interviews
Do we know what symptoms occur in MDD?
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
Loss
of e
nerg
yDi
min
ishe
d dr
ive
Slee
p di
stur
banc
eCo
ncen
trat
ion/
inde
cisi
onDe
pres
sed
moo
d
Anxi
ety
Dim
inis
hed
conc
entr
atio
n
Inso
mni
aDi
min
ishe
d in
tere
st/p
leas
ure
Psyc
hic
anxi
ety
Help
less
ness
Wor
thle
ssne
ssHo
pele
ssne
ssSo
mat
ic a
nxie
tyTh
ough
ts o
f dea
th
Ange
rEx
cess
ive
guilt
Psyc
hom
otor
cha
nge
Inde
cisiv
enes
sDe
crea
sed
appe
tite
Psyc
hom
otor
agi
tatio
nPs
ycho
mot
or re
tard
atio
nDe
crea
sed
wei
ght
Lack
of r
eact
ive
moo
dIn
crea
sed
appe
tite
Hype
rsom
nia
Incr
ease
d w
eigh
t
All Case ProportionDepressed ProportionNon-Depressed Proportion
n=1523
Comment: Slide illustrates sensitivity and specificity of each mood symptom
-0.10
0.00
0.10
0.20
0.30
0.40
0.50A
nger
Anx
iety
Dec
reas
ed a
ppet
ite
Dec
reas
ed w
eigh
t
Dep
ress
ed m
ood
Dim
inis
hed
conc
entr
atio
n
Dim
inis
hed
driv
eD
imin
ishe
d in
tere
st/p
leas
ure
Exce
ssiv
e gu
ilt
Hel
ple
ssne
ss
Hop
eles
snes
s
Hyp
erso
mni
a
Incr
ease
d ap
peti
te
Incr
ease
d w
eigh
t
Inde
cisi
vene
ss
Inso
mni
aLa
ck o
f re
acti
ve m
ood
Loss
of
ener
gy
Psyc
hic
anxi
ety
Psyc
hom
otor
agi
tati
on
Psyc
hom
otor
cha
nge
Psyc
hom
otor
ret
arda
tion
Slee
p di
stur
banc
e
Som
atic
anx
iety
Thou
ghts
of
deat
h
Wor
thle
ssne
ss
Rule-In Added Value (PPV-Prev)Rule-Out Added Value (NPV-Prev)
Comment: Slide illustrates added value of each symptom when diagnosing depression and when identifying non-depressed
GP Recognition of Individual symptomProportion of Individual Symptoms Recognised by GPs
76.1
36.4 34.631.6
21.616.7
13.39.1 8.3 8.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Low m
ood
Insomnia
Hypoc
hondri
asis
Loss
of in
terest
Tearfu
lness
Anxiety
Loss
of en
ergy
Pessim
ism
Anorex
ia
Not Copin
g
O’Conner et al (2001) Depression in primary care.Int Psychogeriatr 13(3) 367-374.
Accuracy of GP’s Diagnoses
955927,6406553
667825,1254050GP -ve
501825152503GP +ve
DepressionABSENT
DepressionPRESENT
Sensitivity48%
PPV 42.8%
Specificity80.1%
NPV 85.1%
Prevalence 19%
N=35 studies
Mitchell, Vaze, Rao Lancet 2009
0
10
20
30
40
50
60
70
80
90
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
McCall et al (2007) Primary Care Psychiatry - Recognition by Severity
Comment: Slide illustrates raw number of people identified by severity on the GHQ. Although the % detection increases with severity, the absolute number decreased due to falling prevalence
GP Accuracy – Detection of Distress by GHQ Score
Medically Unwell Alone
Primary Depression Alone
Secondary Depression
Comment: Slide illustrates concept of phenomenology of depression in medical disease
FatigueAnorexiaInsomnia
Concentration
Study: Coyne Thombs MitchellN= 4500; Pooled database study; All comparative studies
Physical illness+comorbid depression
Vs
Physical illness alone
Vs
Primary depression alone
Co-morbid Depression vs Primary Depression
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Agitatio
n (Com
orbid)
Agitatio
n (Prim
ary)
Anxiety
(Com
orbid)
Anxiety
(Prim
ary)
Appetite
(Comorb
id)
Appetite
(Prim
ary)
Concen
tratio
n (Comorb
id)
Concen
tratio
n (Prim
ary)
Fatigu
e (Comorb
id)
Fatigu
e (Prim
ary)
Guilt (
Comorbid)
Guilt (
Primar
y)
Hopeles
snes
s (Comorb
id)
Hopeles
snes
s (Prim
ary)
Insomnia
(Comor
bid)
Insomnia
(Prim
ary)
Loss In
teres
t (Comorb
id)
Loss In
teres
t (Prim
ary)
Low Mood (C
omorbid)
Low Mood (P
rimary
)
Retard
ation (
Comorbid)
Retard
ation (
Primary)
Suicide (
Comorbid)
Suicide (
Primar
y)
Weight L
oss (C
omorbid)
Weight L
oss (P
rimary
)
*
*
*
*
*
**
*
*
Comorbid Depression
Primary Depression
n=4069 vs 4982Comment: Slide illustrates similar symptoms profile in comorbid vsprimary depression
Medically Unwell Alone
Primary Depression Alone
Secondary Depression
Comment: Slide illustrates assumed overlap of primary and secondary depression
FatigueAnorexiaInsomnia
Concentration
Primary Depression Alone
Secondary Depression
Comment: Slide illustrates actual overlap of primary and secondary depression
AgitationRetardation
Co-morbid Depression vs Medical Illness Alone
n= 4069 vs 1217
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Anxiety
(Com
orbid)
Anxiety
(Med
ical)
Concen
tratio
n (Comorb
id)
Concen
tratio
n (Med
ical)
Fatigu
e (Comorb
id)Fati
gue (
Medica
l)
Hopeles
snes
s (Comorb
id)
Hopeles
snes
s (Med
ical)
Insomnia
(any t
ype)
(Comorb
id)
Insomnia
(any t
ype)
(Med
ical)
Loss In
teres
t (Comorb
id)
Loss In
teres
t (Med
ical)
Low Mood (C
omorbid)
Low Mood (M
edical)
Retard
ation (
Comorbid)
Retard
ation (
Medica
l)
Suicide (
Comorbid)
Suicide (
Medica
l)
Weight L
oss (C
omorbid)
Weight L
oss (M
edical)
Worthles
snes
s (Comor
bid)
Worthles
snes
s (Med
ical)
Medical Illness Alone
Comorbid Depression
**
*
*
*
*
*
*
*
Comment: Slide illustrates distinct symptoms profile in comorbid depression vs medical illness alone
Medically Unwell Alone
Primary Depression Alone
Secondary Depression
Comment: Slide illustrates concept of phenomenology of depressions in medical disease
FatigueAnorexiaInsomnia
Concentration
Medically Unwell
Primary Depression
Secondary Depression
Comment: Slide illustrates actual phenomenology of depressions in medical disease
Weight loss
AgitationRetardation
Elderly?
0.000
0.100
0.200
0.300
0.400
0.500
0.600
0.700
0.800
Anger
Anxiety
(Com
bined)
Anxiety
(Psy
chic
anxie
ty)
Anxiety
(Somatic
anxiet
y)
Decre
ased
App
etite
Decre
ased
Weig
ht
Depres
sed M
ood
Diminish
ed C
oncentra
tion
Diminish
ed In
teres
tExc
essiv
e Guilt
Helples
snes
sHope
lessn
ess
Increas
ed A
ppetite
Increas
ed W
eight
Indecisi
venes
sLoss
of Ene
rgy
Psych
omotor Agita
tion
Psych
omotor Retar
datio
n
Sleep D
isturban
ce (C
ombined)
Sleep D
isturban
ce (H
ypers
omnia)
Sleep D
isturban
ce (In
somnia)
Thoughts
of Dea
thWorth
lessn
ess
<55>54>59>64
*
*
*
*
*
**
*
Comment: Slide illustrates diagnostic value of symptoms in late life vs mid-life depression – few have special significance
3. Cancer Care - Detection
How well do cancer specialists identify depression/distress?
How do doctors compare with nurses?
1,2 or 3 Simple QQ15%
Clinical Skills Alone73%
ICD10/DSMIV0%
Short QQ3%
Other/Uncertain9% Other/Uncertain
2%
Use a QQ15%
ICD10/DSMIV13%
Clinical Skills Alone55%
1,2 or 3 Simple QQ15%
Cancer StaffCurrent Method (n=226)
Psychiatrists
Comment: Current preferred method of eliciting symptoms of distress/depression
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Pos
t-tes
t Pro
babi
lity
Baseline Probability
Depression+
Depression-
PPV
NPV
Comment: At a prevalence of 20% GPs PPV is 40% and NPV 86%
Phase I
Comment: Slide illustrates diagnostic accuracy according to score on DT
11.815.4
30.4 28.9
41.9 42.9 40.7
57.1
82.4
66.771.4
15.8
25.0
26.124.4
19.4 19.0
33.3
21.4
11.8
22.2 14.3
72.4
59.6
43.546.7
38.7 38.1
25.921.4
5.911.1
14.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Zero One Two Three Four Five Six Seven Eight Nine Ten
Judgement = Non-distressedJudgement = UnclearJudgement = Distressed
ResultsLooking for just distress
detection sensitivity of 11.2% (95% CI 6.9% to 16.9%)
detection specificity of 98.3% (95% CI 95.2 to 99.7%).
Looking for any mental health complication their
sensitivity was 50.6%
specificity 79.4%
There was significantly better performance using the broad approach rather than a narrow focus 65.4% vs 56% (Chi² = 4.3,p = 0.037).
PredictorsExamining predictors, clinicians had better ability to
recognize higher severities of distress (adjusted R2= 0.87 p = 0.001). There was a trend for better recognition by community than chemotherapy nurses. There was no difference according to the stage or type of cancer.
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post
-test
Pro
babi
lity
CHEMO+
CHEMO-
Baseline Probability
COMMU+
COMMU-
Detection sensitivity = 50.6%Detection specificity = 79.4%Overall accuracy = 65.4%.
Comment: Slide illustrates performance of chemotherapy vs community nurses in oncology
SummaryDetection of depression is low in all groups
Detection of depression has some untested assumptions
Most clinicians are not using tools
Detection of distress is almost imperfect
=> Whose opinion is most important